| Background and ObjectivesChronic Venous Insufficiency(CVI) is one of the most common diseases of vascular surgery. The early stage of CVI could be asymptomatic, while the later stage is typically presented with swelling, heaviness, tortuous superficial vein when standing up, as well as rough skin, hyperpigmentation and ulceration. Varicose veins of lower extremity(VVLE)is a major cause of CVI. With the development of ultrasound imaging, the value of two-dimensional and color Doppler ultrasonography in diagnosing CVI increases obviously. Color Doppler flow imaging(CDFI) may present directly the reflux of valve;and Pulse wave Doppler(PWD) may assess the grade of valvular function. It is already a necessary method of clinical evaluation of CVI. However, the CVI diagnosis effectiveness is affected by many factors, such as the great dependence on the operators, non-standard evaluation criteria of valvular function, and the inconsistent knowledge level of the role of perforating veins. Therefore, we studied the patients with deep venous valve insufficiency,whose main clinical manifestations is the varicose great saphenous vein. The systematicultrasound examination were performed with two-dimensional and color Doppler ultrasonography. Every patient underwent a thorough examination from superficial vein to deep vein and perforating veins. The aim of this study is to evaluate the clinical application of ultrasonography in CVI diagnosis, and the weight of perforating vein in the incidence of CVI by comparing with the golden standard X-ray radiography.Methods1. Research SubjectsA group of 107 patients with vein valve insufficiency of lower extremity(150 affected legs) were enrolled in this study. The major clinical symptom is great saphenous vein(GSV) varicosity. The group was divided according to the degree of the clinical symptoms.20 healthy adults( 40 healthy legs) were enrolled as the control group. 12 out of 107patients(CEAP 4-6), 16 pieces of extremities were selected to have the X-ray radiography(8 male and 4 female). The results were compared with ultrasonography.2. Examination MethodsAll patients were performed with ultrasound examination of the lower extremity veins.The full process of GSV was tracted and recorded. Thrombosis in the trunk of GSV, depth and diameter of superficial veins, and the quantity of open perforating veins were marked.The reflux duration and speed of valve, the valve functions of the affected veins and grade of the insufficient valve was evaluated according to the reflux duration. Patients underwent X-ray Ascending phlebography(AP) examination to record the valve function of the affected veins and the location of open perforating veins. The valve functions of the perforating veins were evaluated.3.Statistical AnalysisData were analyzed by statistical analysis application software SPSS13.0, and measured in the format of mean and standard deviation. Measurement data were analyzed with One-Way ANOVA method, and Tukey’s Test method was applied for cross-group comparison. Ranked data and enumeration data cross groups were validated with χ2Test method or Fisher’s exact test. The correlation between parameters was analyzed by Pearson Correlation Coefficient and linear regression analysis method. P<0.05 wasstatistically significant. The examination results from ultrasound and X-ray AP of the same patient were validated by Matched T-test, and P<0.05 was statistically significant. The examination results of X-ray were benchmarked to measure the sensitivity and specificity of the ultrasound examination of insufficient perforating veins. The consistency between the results of the two examination methods was analyzed by measuring Cohen’s Kappa.The consistency is considered reliable if kappa is less than 0.6.Results1. The perforating veins of lower limb in control group could not be clearly displayed by two-dimensional ultrasound, there was only 4 perforating veins were detected by CDFI under squeezing test, the demonstration rate was 4/40.2. The GSV diameter of the affected legs in the case group saw obvious increase in width. 6.67%(10 out of 150, all from C5~6 group) were found with thrombosis on the distal end of the vein. The GSV diameter of C5~6 patients were widened obviously(P<0.01); 94.67%(142 out of 150) of the VVLE patients were diagnosed with GSV valve insufficiency in their affected legs, among which 123 legs suffer from serious valve insufficiency. The percentage variance of such symptoms was not significant among different clinical graded groups(P>0.05). It is positive correlation between the GSV reflux speed and the insufficiency of femoral vein valve(r=0.2952,P=0.0003).3. There were 114(114 out of 150, 76% of all samples) affected legs were diagnosed with perforating veins. 185 open perforating veins were found, 95.1%(176 out of 185) of which were found in the shank(Cockett perforating veins). The diameter of perforating veins of C5~6 patients saw obvious increase of 3.778±1.163mm(P=0.0483), and the reflux rate of perforating veins increased as well(P=0.043). The number of open perforating veins, its diameter and reflux are in significant positive correlation(r=0.3674,P=0.0036;r=0.2764,P=0.0006). The more reflux in perforating veins, the worse the GSV valve functions(r=-0.2443,P=0.0026).4. Benchmarking the results of X-ray AP before the surgery, the sensitivity of perforating veins was 86.6%, specificity was 82.3%, correction index was 0.689, diagnosis eligibility was 85.1%, Kappa was 0.682; The physical and psychological comfort scoreafter X-ray AP are both higher than ultrasound examination(the lower the scores, the higher the comfort level of patients), and the variance between the two was statistically significant(P<0.001).Benchmarking the results of X-ray AP before the surgery, the sensitivity of perforating veins was 86.6%, specificity was 82.3%, correction index was0.689, diagnosis eligibility was 85.1%, Kappa was 0.682; The physical and psychological comfort score after X-ray AP are both higher than ultrasound examination(the lower the scores, the higher the comfort level of patients), and the variance between the two was statistically significant(P<0.001).Conclusions1. The perforating veins of lower limb in healthy group could not be clearly displayed by two-dimensional ultrasound, the demonstration rate was low.2. Incompetent perforating vein is characterized as wide diameter and longer duration of reverse blood flow. The opening and the hemodynamic changes of perforating veins will affect the hemodynamic changes of the GSV and femoral vein, and lead to the different clinical grading of patients. To evaluate the form and function change of affected veins by using ultrasound could be helpful in evaluating the pathological changes of varicose veins, and providing diagnostic reference for treatment.3. Compared with X-ray AP, there is no significant difference between X-ray AP and ultrasound in the detection rate of the abnormal perforating vein. However, patient’s comfort level of ultrasound examination is outstandingly better than X-ray AP, so that ultrasound imaging could be considered as the preferred choice for diagnosing CVI. |
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